Sociocultural explanations of schizophrenia

Labelling

Some clinicians have questioned whether schizophrenia actually exists

Thomas Szasz (1979) stated that labelling someone with schizophrenia is simply the 'medicalisation of madness' and using terms such as 'treatment', 'illness' and 'diagnosis' is a form of social control that robs individuals of their freedom.

Labelling excludes those who don't conform to social or cultural norms.

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Labelling - Scheff (1966)

Scheff proposed that schizophrenia is a learned social role that is determined by the process of labelling.

His labelling theory proposed that an individual who breaks one or more residual rules are assigned as 'mentally ill' or 'schizophrenic.'

This label does not only influence the individual to behave as a stereotype that fits the label, but it also determines how others react to the behaviour of that person

Individuals accept their new social role and consequently find it difficult to fit back into normal society. If other people discover they are 'mentally ill' they may find it difficult to find work, and if they are hospitalised, this further reinforces their perception and expectations. The diagnosis of 'schizophrenia' creates a self fufilling prophecy.

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Labelling - Rosenhan (1973)

Wanted to investigate the reliablity of diagnosing a mental illness

A group of eight 'pseudo patients' free from psychological symptoms, pretended they could hear an unfamiliar voice (auditory hallucination) which said 'empty', 'hollow' and 'thud' in order to gain admission into a varietyy of hospitals across the US.

All patients were admitted to hospital, seven with the diagnosis of being 'schizophrenic.'

The patients behaved normally once admitted and reported a sense of powerlessness and fear, again, their behaviour was interpreted by staff as being 'schizophrenic.'

Following admissions, patients had trouble convincing staff that they were sane and they were hospitalised for 7 to 52 days. 'Normal' behaviour was percieved as 'abnormal' - eg, writing notes was deemed as 'obsessive-compulsive writing behaviour.'

Once labelled 'schizophrenic' the label stuck, and patients were discharged with 'schizophrenia in remission.'

The unreliablity of diagnosing a serious disorder was evident, and patients were percieved according to the labels they were given.

This study and follow up study helped improve the reliablity of diagnosing schizophrenia.

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Evaluation of labelling theory

The Rosenhan study helped to improve the reliablity of the diagnosis with the revision of the diagnositc criteria (DSM-III, 1980). The study suggested that psychiatric labels often become self-fulfilling prophecies, and that often people begin to interpret the behaviour in a way that 'fits in' with our pre-existing assumptions and beliefs.

Labelling theory only accounts for how symptoms are maintained, it does not explain the cause, nor does it offer any kind of treatment.

Labelling theory ignores compelling genetic and biological evidence

There are seriously ill individuals with a range of debilitating symptoms exist that require help. and labelling theory has been criticised for trivilaising a very serious disorder.

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Family dysfunction - Early studies into family pat

Early studies into family influences and schizophrenia looked at the nature and style of communication within these famlies.

Bateson et all (1956) suggested that the communication between parents an offspring was sometimes contradictory; they used the phrase 'double blind.'

A parent may be saying one thing, yet their body language and tone could be suggesting the opposite. Children experiencing such 'double blinds' learn not to trust their own feelings and perceptions, as they cannot trust those of others. They grown up to mistrust all communications, as shown in people with paranoid schizophrenia.

According to family socialisation theory, families sometimes fail to provide a stable and supportve environment, and appropriate role models fo the developing child (Lidz et al 1957) and there are two abnormal family structures:

Schismatic families: In these families, conflicts between parents result in competition for the affection of family members and a desire to take control and undermine the other parent

Skewed families: In these, one partner is abnormally dominating and the other submissive. The children are encouraged to follow the dominant partner which impairs their cognitive and social development.

In both types of family, parents fail to act in role-appropriate ways, which can cause anxiety and schizophrenia may be a way of handling family conflicts.

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Evaluation of early studies

Although associations have been found between family patterns and schizophrenia, it is difficult to prove a causal relationship as it is impossible to untangle cause and effect.

It may be the parent's reaction to a particularly difficult child that causes the family problems, rather than the family problems causing problems in the child.

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The expressed emotion explanation

A series of studies into 'expressed emotion' have investigated family and the course of schizophrenia.

In an early study, Brown et al found, to their surprise, that people with schizophrenia who were discharged from hospital and returned to parents or spouses fared worse than those returning to lodging, high face-to-face contact between patient and family was found to increase risk of relapse, and this was attributed to the relatives' 'emotional over-involvement.' Emotional over-involvement was operationalised to include:

Emotions (positive and negative)

Hostility

Critical comments (tone of voice and content.)

When these factors are high in a household, ie, where the expressed emotion is high, patients are significantly more likely to relapse than if the patient lived in a family with low expressed emotion.

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Bebbington and Kuipers (1994)

Carried out a meta-analysis of 26 prospective studies of the role of expressed emotion as a risk factor for relapse in schizophrenia for a variety of countries including the UK, USA, Switzerland and Japan from 1958-1990s.

Data relating to 1,346 patients were analysed to determine:

The proportion of expressed emotion families

The relapse rate for people with schizophrenia, returning to high- and low-expressed emotion patients.

52% of families were high expressed emotion. Relapse in the high expressed emotion families averaged at 50%, whilst in the low expressed emotion families, it was 21%.

Expressed emotion is a significant risk factor in relapse rates for schizophrenia.

It is, however, as with many studies, difficult to establish cause and effect - do schizophrenics cause families to become high in expressed emotion or is it the families that cause schizophrenia?

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Evaluation of the expressed emotion explanation

The ability to predict the relapse rate of people with schizophrenia from the expressed emotion measure up to 12 months following discharge is a strong indicator of the prescriptive validity (how well a measure accuratley predicts what you intend to measure) of the expressed emotion.

It is unclear whether expressed emotion is a casual agent in relapse rates, or just a reaction to the patient's behaviour. If the condition of a person with schizophrenia begins to deteriorate, family involvement is likely to increase, along with family criticism and efforts to control the situation. These all come under the remit of 'expressed emotion.' (Kanter et al 1987).

Recent studies (eg, Kavanagh, 1992) have found that high expressed emotion communication patterns are not specific to schizophrenia; they are also found in families with depressive illness and eating disorders. This type of communication pattern is also more evident in western families (Leff et al, 1990).

There is a problem with how expressed emotion is measured, which is usually via one interview. This may not be sufficient to give an accurate picture of family interaction patterns.